Gastrointestinal (GI) Condition with Bleeding
Gastrointestinal (GI) bleeding is not a disease but a symptom of a disorder in a person’s digestive tract. There are many possibilities that may cause GI bleeding, including hemorrhoids, peptic ulcers, diverticulosis/diverticulitis, ulcerative colitis, Crohn’s disease, colonic polyps, or gastritis (just to name a few examples). Per ICD-10-CM Official Guidelines for Coding and Reporting Section I.A.15 “With” guideline, it is safe to presume a causal relationship between two conditions when it is linked by the term “with” or “in” when it appears in a code title. In that case, when a provider documents that a patient has one of the previously mentioned conditions (among other conditions) and GI bleeding, then it is appropriate to assume a relationship between the disorder and bleeding. The ONLY time it is not acceptable is when documentation clearly states that the conditions are unrelated or if the physician documents a different cause of the bleeding.
Q: A 66-year-old female was admitted with nausea and vomiting with hematemesis. The history and physical documentation notes “hematemesis, one episode, likely from gastritis”. An EGD was performed. Discharge summary states the following final findings: “gastritis, which was biopsied” along with “hematemesis, one episode, likely from gastritis”.
A: K29.71, Gastritis, unspecified, with bleeding
Reference: AHA Coding Clinic Third Quarter 2018, page 22: Hematemesis due to Ulcerative Esophagitis and Duodenitis
